Complexities in Prognostication in Advanced Cancer: Title and subTitle Break"To Help Them Live Their Lives the Way They Want to"

On July 2, 2002,¹ authors Elizabeth B. Lamont, MD, MS, and Nicholas Christakis, MD, PhD, MPH, introduced Miss M, an 83-year-old woman. She had presented to Dr D on August 2, 1999, with several suspicious skin lesions on her abdomen. Dr D suspected metastatic cancer. A couple of weeks later, she was admitted to the hospital with abdominal pain, nausea, and vomiting and was found to have an infiltrative narrowing of the colon. Biopsy results showed adenocarcinoma suggestive of gastric origin. The patient and physician had a thorough discussion of chemotherapy vs comfort-oriented therapy. On the basis of the additional pathological finding of estrogen-receptor-positive cells, Dr D suggested an empiric trial of hormonal therapy with tamoxifen as an alternative to chemotherapy, which Miss M accepted. At that time, in the presence of supportive friends and family, Dr D told Miss M that she thought her prognosis was on the order of months; she estimated that Miss M would probably die by Christmas.

To Dr D's surprise, Miss M stabilized despite some initial weight loss, and the lesions on her abdomen shrank and disappeared. Miss M and Dr D were interviewed for the article in June 2002, some 33 months after the 3-month prognosis was delivered.

In the Perspectives article, the authors acknowledge that predicting survival and disclosing the prediction to patients with advanced disease, particularly cancer, is among the most difficult tasks that physicians face. The authors emphasize the importance of accurate diagnosis because this clear starting point sets the stage for making a prognosis at all. The authors discussed several resources to aid physicians in presenting more accurate prognoses to their patients, including "disinterested" physicians or tumor boards, and Surveillance, Epidemiology, and End Results stage–specific survival curves, as well as performance status. Finally, algorithms to help break bad news were presented.

Dr D wrote the Perspectives' editors the following letter about Miss M, shortly after she died in early July 2003.

Miss M died peacefully on Sunday afternoon. She was fully dressed until a week before and last got out of bed 5 days before. She was ready, and contented, and peaceful. We had a great conversation the night of July 3rd. She was so beautiful, she glowed. The Memorial Service is Saturday–probably will be SRO!

An obituary contained the following remembrance:

Throughout her life, Miss M welcomed friends and relatives of all ages to her home, where food, stimulating conversation and music flowed in an atmosphere of love and acceptance. . . . She is survived by a great number of people whose lives she uniquely touched.